Healthcare Provider Details

I. General information

NPI: 1861830101
Provider Name (Legal Business Name): PHYLLIS A ALLEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2013
Last Update Date: 06/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4010 N MAIN ST SUITE 2
COLUMBIA SC
29203-5848
US

IV. Provider business mailing address

4010 N MAIN ST SUITE 2
COLUMBIA SC
29203-5848
US

V. Phone/Fax

Practice location:
  • Phone: 803-786-0559
  • Fax: 803-786-1307
Mailing address:
  • Phone: 803-786-0559
  • Fax: 803-786-1307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number3
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: